Take the Critical Care Challenge

Posted by • August 15th, 2013

A 77-year-old man is admitted to the ICU after resection of the rectosigmoid colon for gross fecal peritonitis.

What should be done first?

On August 29th, we will publish the first article in a new series on Critical Care, Severe Sepsis and Septic Shock. In advance of its release, we have published a case on NEJM.org that highlights issues raised in that article.  Read the case, take the poll, and comment.

Which of the following therapies should be instituted with the goal of reducing this patient’s risk of dying from septic shock?

1. Treatment with intravenous gamma globulin(IVIg)

2. Treatment with intravenous hydrocortisone 50mg q8 hourly

3. Treatment with a hydroxymethylglutaryl coenzyme A reductase inhibitor (a statin)

To learn more, read the editorial published this week by guest editors Drs. Simon Finfer and Jean-Louis Vincent.  We hope you enjoy this new series.

19 Responses to “Take the Critical Care Challenge”

  1. Divyani says:

    IV hydrocortisone 50 mg q8h for relative adrenal insuficiency in septic shock

  2. Raj Shetty says:

    Out of the three, only one I would consider in sepsis is hydrocortisone though not in this case. Here fluids (crystalloid or colloid) will be the main course of the treatment as he will be third spacing. With SIRS response he will be vasodilated and will benefit from vasopressor (noradrenaline) to maintain the perfusion pressure.Antibiotics to cover the gram negatives and anaerobes (ceftriaxone and metronidazole). Ensure he is warm and well anagesed! Then I will wait and watch for response to my treatment….

  3. Igors says:

    Treatment with intravenous gamma globulin(IVIg)

  4. majd kanbour says:

    answer is number 2 IV hydrocortisone

  5. Ibrahim JUDA says:

    Treatment with a hydroxymethylglutaryl coenzyme A reductase inhibitor.

  6. Dr Wimal Dissanayake says:

    Treatment with intravenous hydrocortisone 50mg @ 6 hourly

  7. souhia says:

    Treatment with intravenous gamma globulin(IVIg)

  8. jose aizpurua says:

    1. Treatment with IV Gamma Globulin.

  9. DR Vijayalakshmi R Shetty says:

    1

  10. ashish says:

    2. Treatment with intravenous hydrocortisone 50mg q8 hourly

  11. anubhav sharma says:

    continue inotrops,send blood culture,cvp should be placed as soon as possible,scvo2 should be done and hct should be measured,,if scvo2 is less then he need more fluids otherwise give prbc or dobutamine according to the scvo2 and hct report.can add vasopressin if map is less then 65..add hydrocortisone is required.,monitor urine output hourly

  12. girish says:

    Oxygenation, goal directed fluid – normalising lactate and SvO2 as goal, Meropenam, inotrops, Steroids if unresponsive to 0.2mcg/kg/min of noradrenaline, early source control, keep abdomen open until hemodynamics settles, cardiac output monitoring and vasopressin if SVR still remains low on norad, Dobutamine if low cardiac output,

  13. Wanis Shali says:

    Treatment with I’ve hydrocortisone will reduce the mortality in patient treated from septic shock, statin may he will get benefit from it if he already in statin preoperation

  14. DR Bashir Ahmed khuhro says:

    Treatment with intravenous hydrocortisone 50mg q8 hourly –

  15. vanisha says:

    IV gamma globulins

  16. Benny Schulz says:

    The use of statines isn’t that far fetched as it might sound first and IVIg seem right a priori, but I have to say next to the basic of a broad antibiotic treatment with imipenem or meropenem and fluid therapy (and norepinephrine) I’d go with the hydrocortisone though I would set up a slightly higher dose of 75mg q8. Explanation:
    The decision is mainly based on the rare information- if the mentioned is everything we know at this point and a decision for the treatment has to be made. The previous heavy alcohol intake made me to tend away from the statines and immunglobulines. I’d give up their most likely positives effects on the inflammation for the establishment of an improved haemodynamic situation, which I find the hydrocortison most promising for taking the hypertension and a presumed adaptation to higher bloodpressure levels into account. All three options are discussworthy on their benefit for the outcome and I can see people setting for the other options, but for me the hydrocortison stays the most reasonable option based on the level of information given.

  17. pkgupta says:

    Treatment with intravenous hydrocortisone 50mg q8 hourly –

  18. ausaf says:

    hydrocortisone will help in this patient . It has synergistic effect with nor epinephrine in increasing blood pressure.

  19. nageen says:

    iv steroids, iv antibiotics and vassopressors